An adult who fell 20 feet (6 meters) from a tree is admitted to the intermediate intensive care unit with a fractured femur. When the cardiac monitor alarms, the nurse finds the client has no palpable carotid pulse and no spontaneous respiration, however, the cardiac monitor displays a sinus rhythm. Which intervention should the nurse implement?
View the rhythm in another chest lead.
Begin chest compressions at a rate of 120 times a minute.
Auscultate all chest fields for muffled lung sounds.
Observe for swelling at the fracture site.
The Correct Answer is B
A. View the rhythm in another chest lead. While verifying the rhythm in another lead may help confirm the accuracy of the monitor, it does not address the immediate absence of a pulse and respirations. The client is in pulseless electrical activity (PEA), which requires immediate intervention rather than rhythm verification.
B. Begin chest compressions at a rate of 120 times a minute. The client has no palpable carotid pulse and no spontaneous respirations despite a sinus rhythm on the monitor, indicating pulseless electrical activity (PEA). PEA is a form of cardiac arrest where the heart shows electrical activity but fails to generate effective circulation. Immediate high-quality chest compressions are essential to maintain perfusion while addressing the underlying cause, such as hypovolemia or tension pneumothorax.
C. Auscultate all chest fields for muffled lung sounds. While assessing for muffled lung sounds may help detect conditions such as tension pneumothorax or hemothorax, it should not delay the initiation of CPR. Once compressions are started, the underlying cause of PEA can be investigated.
D. Observe for swelling at the fracture site. Swelling at the fracture site may indicate bleeding or compartment syndrome, but assessing the fracture should not take priority over initiating CPR. If hemorrhage is suspected as a cause of PEA, rapid fluid resuscitation should be initiated after starting chest compressions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Narrowed pulse pressure, presence of 3+ femoral pulses, apneic episodes. Narrowed pulse pressure is consistent with hypovolemic shock, but 3+ femoral pulses are not expected, as shock leads to weak, thready pulses due to reduced perfusion. Apneic episodes typically occur in the late stages of shock, not in the early or progressive stages.
B. Widening pulse pressure, muffled heart sounds, presence of atrial gallop. A widening pulse pressure and muffled heart sounds are more indicative of cardiac tamponade, not hypovolemic shock. Hypovolemic shock is characterized by a narrowing pulse pressure due to a drop in systolic blood pressure while diastolic pressure remains relatively stable.
C. Increased heart rate, lowered systolic reading, peripheral extremity mottling. Tachycardia is an early compensatory response to hypovolemia as the body attempts to maintain cardiac output. As shock progresses, systolic blood pressure drops due to inadequate circulating volume. Peripheral extremity mottling occurs as the body shunts blood to vital organs, reducing perfusion to the skin. These signs are characteristic of progressive hypovolemic shock.
D. Irregular heart rate, elevated diastolic reading, increased respiratory rate. An irregular heart rate is not a primary indicator of hypovolemic shock. While respiratory rate increases in response to decreased oxygen delivery, an elevated diastolic reading is uncommon, as diastolic pressure tends to stay stable or decrease slightly with ongoing hypovolemia.
Correct Answer is ["9"]
Explanation
Calculation:
Calculate the dopamine dose in mcg/min:
Dose = 2 mcg/kg/min
Weight = 60 kg
Dose per minute = 2 mcg/kg/min × 60 kg
= 120 mcg/min
Calculate the dopamine dose in mcg/hour:
Dose per hour = 120 mcg/min × 60 min/hour
= 7200 mcg/hour
Convert mcg to mg:
Dose per hour = 7200 mcg/hour / 1000 mcg/mg
= 7.2 mg/hour
Calculate the concentration of dopamine in the IV bag:
Dopamine: 400 mg
Solution: 500 mL
Concentration = 400 mg / 500 mL
= 0.8 mg/mL
Calculate the infusion rate in mL/hour:
Dose per hour: 7.2 mg/hour
Concentration: 0.8 mg/mL
Infusion rate = 7.2 mg/hour / 0.8 mg/mL
= 9 mL/hour
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